The Mental Status Exam The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes the mental state and behaviors of the person being seen. It includes both objective observations of the counselor/case manager and subjective descriptions given by the patient/client. Why do we do them? The mental status exam (MSE) provides information for diagnosis and assessment of mental health and substance use disorders. This information is then utilized to develop the Treatment Plan. The MSE provides a snap shot at a point in time so that if another provider sees your patient it allows them to determine if the client’s status has changed without previously seeing the client. To properly assess the MSE, information about the client’s history is needed including education, cultural and social factors which you will be collecting during the biopsychosocial assessment. Components of the Mental Status Exam: Appearance Behavior Speech Mood Affect Thought process Thought content Cognition Insight/Judgment What do you see? You will describe the client’s physical build, how the client looks compared with his or her age, posture, dress, grooming, and any prominent physical abnormalities. You will comment on the client’s level of alertness, emotional facial expressions, and his/her attitude toward you, the interviewer. Physical appearance of client: how he/she was dressed: appropriate casual attire, dressed in Sunday best, dressed in a sexually provocative manner, clothing was dirty, torn in places, poor fit (too large or too small), no shoes, mismatched shoes, unkempt, unclean appearance grooming: well-groomed, immaculate, attention to detail, hair was oily-unwashed, unusual hair color, heavily made up, malodorous, unshaven; distinguishing features: scars, tattoos, bandages, bloodstains, missing teeth, tobaccostained fingers; body build: thin, obese, athletic, medium, average build/size for his/her height; physical integrity: missing limb, jaundice, profuse sweating, goiter, wheezing, coughing, illor well-appearing. Motor activity: restlessness, agitation, pacing, wringing of hands, inability to sit still, nervous shaking leg (s), tremors, abnormal movements, tics, or psychomotor retardation: lethargic, generalized slowing of physical and emotional reactions. Note any unusual facial movements. Gait: manner of walking, stepping, or running, may be unusual, unsteady, staggered walking pattern, difficulty walking, painful walk, uncontrollable walking patterns, walked stifflegged, shuffling, broad-based, limping, stumbling, hesitation Body posture: slouched in chair, good posture, sat on edge of seat Eye Contact: poor, good, fleeting, sporadic, avoided, intermittent, piercing, none General behavior: congenial, cooperative, open, candid, engaging, relaxed, withdrawn, guarded, hostile, irritable, resistant, shy, defensive Speech: Rate: increased/pressured, decreased/monosyllabic, latency Rhythm: articulation, prosody, dysarthria, monotone, slurred Volume: loud, soft, mute Content: fluent, loquacious, paucity, impoverished Mood: The prevalent emotional state the client tells you they feel Often placed in quotes since it is what the patient tells you Examples “Fantastic, elated, depressed, anxious, sad, angry, irritable, good Affect: the emotional state we observe Type: euthymic (normal mood), dysphoric (depressed, irritable, angry), euphoric (elevated, elated) anxious; Range: full (normal) vs. restricted, blunted or flat, labile; Congruency: does it match the mood- (mood congruent vs. mood incongruent); Stability: stable vs. labile Thought Process: Describes the rate of thoughts, how they flow and are connected. Normal: tight, logical and linear, coherent and goal directed Abnormal: associations are not clear, organized, coherent. Examples include circumstantial, tangential, loose, a flight of ideas, word salad, clanging, thought blocking. Circumstantial: provide unnecessary detail but eventually get to the point Tangential: Move from thought to thought that relates in some way but never gets to the point Loose: Illogical shifting between unrelated topics Flight of ideas: Quickly moving from one idea to another Thought blocking: thoughts are interrupted Perseveration: Repetition of words, phrases or ideas Word Salad: Randomly spoken words Thought Content: Refers to the themes that occupy the client's thoughts and perceptual disturbances Examples include preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions Thought Content Examples Preoccupations: Suicidal or homicidal ideation (SI or HI), perseverations, obsessions or compulsions Illusions: Misinterpretations of environment Ideas of Reference (IOR): Misinterpretation of incidents and events in the outside world having direct personal reference to the patient Hallucinations: False sensory perceptions. Can be auditory (AH), visual (VH), tactile or olfactory Derealization: Feelings the outer environment feels unreal Depersonalization: Sensation of unreality concerning oneself or parts of oneself Delusions: Fixed, false beliefs firmly held in spite of contradictory evidence Control: outside forces are controlling actions Erotomanic: a person, usually of higher status, is in love with the patient Grandiose: inflated sense of self-worth, power or wealth Somatic: patient has a physical defect Reference: unrelated events apply to them Persecutory: others are trying to cause harm Cognition: Level of consciousness Attention and concentration: the ability to focus, sustain and appropriately shift mental attention Memory: immediate, short and long term Abstraction: proverb interpretation Insight/Judgment: Insight: awareness of one’s own illness and/or situation Judgment: the ability to anticipate the consequences of one’s behavior and make decisions to safeguard your well being and that of others Summary By the end of a standard biopsychosocial assessment interview, most of the information for the MSE has been gathered. The MSE provides information for diagnosis and assessment of disorder and response to treatment over time. Remember to include both what you hear and what you see!
